UTAH DEPARTMENT OF ALCOHOLIC BEVERAGE CONTROL 1625 S 900 W x PO Box 30408 x Salt Lake City, Utah x 84130-0408 x (801) 977-6800 x Fax 977-6888 website: www.abc.utah.gov “SPECIAL USE PERMIT” (PUBLIC SERVICE) APPLICATION CHECKLIST The items below should be completed and submitted by the 10th of the month or earlier, so that your application can be processed in a timely manner. All licensing requirements must be fully satisfied in order to complete your application. You will be notified of the next monthly Utah Alcoholic Beverage Control Commission meeting when your application will be considered for issuance of a license. 1.____Completed application form (enclosed). 2.____Ownership entity organizational papers for business: a) if a corporation, submit a copy of articles of incorporation; b) if a partnership, submit a copy of written agreement; c) if a limited liability company, submit a copy of articles of organization. 3.____Criminal history background check information (see application form). 4.____Written consent from either city/town council or county commission, whichever is applicable (form enclosed). 5.____$1,000 special use permit cash or corporate surety bond (form enclosed). 6.____Scaled floor plan (8 ½”x11”) of hospitality room premises only, highlighting the areas where alcohol will be stored, sold and consumed and also reflecting distance between room and terminal area used by carrier. 7.____$50 application fee (nonrefundable). 8.____$200 initial license fee (make checks payable to UDABC). Enclosed are copies of Utah laws and rules pertaining to Public Service Special Use permits. If you have questions concerning these forms or the application process, please contact our Licensing and Compliance Division at (801) 977-6800. American LegalNet, Inc. www.FormsWorkflow.com 6.05.08 UTAH DEPARTMENT OF ALCOHOLIC BEVERAGE CONTROL APPLICATION FOR SPECIAL USE PERMIT (PUBLIC SERVICE) 1. Applicant/Organization:____________________________________________________ 2. Business Name:___________________________________________________________ 3. Location: _______________________________________________________________ Street City State Zip 4. Mailing Address:__________________________________________________________ Street P O Box City State Zip 5. Business phone: ______________ Other phone:______________ Fax: _______________ 6. Contact person: _____________________________ e-mail: _______________________ 7. Ownership: Check appropriate box and provide the requested information in the space below. (add additional sheets if necessary). [] Applicant is an individual: List below information for: (a) Individual [] Applicant is a partnership: List below information for: (a) All Partners [] Applicant is a corporation: List below information for: (a) Any Stockholder owning at least 20% of the corporation (b) All Corporate officers and Directors [] Applicant is a limited liability company (LLC): List below information for: (a) Any members owning at least 20% of the company TITLE____________NAME_______________________HOME ADDRESS_________________________________ HOME PHONE#______________DR LIC#_____________SS#______________DOB__________%OWNED_____ Are you a United States Citizen? ________ If no, must attach a copy of residency status. TITLE____________NAME_______________________HOME ADDRESS_________________________________ HOME PHONE#______________DR LIC#_____________SS#______________DOB__________%OWNED_____ Are you a United States Citizen? ________ If no, must attach a copy of residency status. TITLE____________NAME_______________________HOME ADDRESS_________________________________ HOME PHONE#______________DR LIC#_____________SS#______________DOB__________%OWNED_____ Are you a United States Citizen? ________ If no, must attach a copy of residency status. TITLE____________NAME_______________________HOME ADDRESS_________________________________ HOME PHONE#______________DR LIC#_____________SS#______________DOB__________%OWNED_____ Are you a United States Citizen? ________ If no, must attach a copy of residency status. 6.05.08 American LegalNet, Inc. www.FormsWorkflow.com 8. Criminal History. The law prohibits any person who has been convicted of a felony under any federal or state law or any violation of any federal or state law or local ordinance concerning the sale, manufacture, distribution, warehousing, adulteration, or transportation of alcoholic beverages from being in the alcoholic beverage business. The law also prohibits any person who has been convicted of any crime involving moral turpitude or, on two or more occasions within the last five years, has been convicted of driving under the influence of alcohol, or any drug, or the combination of alcohol and any drug from being in the alcohol business. This proscription also applies to any officers, partners, managers, managing agents, directors, stockholders who hold at least 20% of the total issued and outstanding stock of an applicant corporation, members who own at least 20% of an applicant limited liability company and to any person employed to act in a supervisory or managerial capacity. Please list all criminal offenses other than minor traffic offenses of which you or any of the above persons have ever been convicted: NAME CRIMINAL OFFENSE DATE OF CONVICTION In addition, a criminal history background check must be furnished on each person listed above and in subparagraph 7. This may be done as follows: a. Utah residents: If any person listed has been a resident of Utah for at least two years, he/she shall submit a fingerprint card to the DABC and consent to a fingerprint criminal background check by the Utah Bureau of Criminal Identification. b. Non Residents: Out of state residents or persons who have resided in Utah for less than two years shall submit a fingerprint card to the DABC and consent to a fingerprint criminal background check by the Federal Bureau of Investigation (F.B.I). An informed consent and release of liability form is included with this application. Fingerprint cards are available at law enforcement agencies. You may download the fingerprint card at this web address: http://www.fbi.gov/hq/cjisd/pdf/fpcardb.pdf Submit the form(s) to the DABC with a processing fee of: • $15.00 per card for BCI background checks, or • $34.25 per card for FBI background checks. In the case of an undue delay in the processing of an F.B.I. criminal background check, here are the rules and procedures for obtaining a third-party national background check: An application that requires F.B.I. criminal history background report(s) may be included on a commission meeting agenda, and may be considered by the commission for issuance of a license, permit, or package agency if: 1). the applicant has completed all requirements to apply for the license, permit, or package agency other than the department receiving the F.B.I. criminal history background report(s); 2). the applicant attests in writing that he or she is not aware of any criminal conviction of any person identified in the application that would disqualify the applicant from applying for and holding the license, permit, or package agency; 3). the applicant has submitted to the DABC the necessary fingerprint card(s) required for the application and consented to the fingerprint criminal background check(s) by the F.B.I. 4). the applicant at the time of application supplies the department with a current criminal history background report conducted by a third-party background check reporting service on any person for which an F.B.I. background check is required; and 5). the applicant stipulates in writing that if an F.B.I. report shows a criminal conviction that would disqualify the applicant from holding the license, permit, or package agency, the applicant shall immediately surrender the license, permit, or package agency to the department. 6.05.08 American LegalNet, Inc. www.FormsWorkflow.com A suggested attestation/stipulation letter that satisfies the above requirements is enclosed. A third-party national criminal background check can be obtained by; • searching the yellow pages under Background Screening • searching the internet under Background Screening or Background Checks Because the DABC is State Agency, we cannot recommend any one background screening service over another. It is your responsibility however, to obtain the most complete, nationwide, criminal history available for the application process. 9. Have you as an applicant, or any proprietor, partner, managing agent, director, officer, stockholder owning at least 20% corporation stock, or if a limited liability company, any member owning at least 20% of the company, had a state alcoholic beverage license, permit, or agency revoked within the last three years? [ ] YES [ ] NO If YES, please explain: _______________________________________________ _________________________________________________________________________________ 11. Does applicant propose to utilize a “hospitality room” where liquor will be sold or served to persons while in transit? _____ If yes, attach floor plan for such facility showing its location and highlighting the sale, consumption and storage areas and the distance between the room and the terminal area. 12. List total of regularly numbered passengers flights, trains, etc:______________________________ ________________________________________________________________________________ 13. List any other storage locations for alcoholic products:____________________________________ ________________________________________________________________________________ 14. By signing below, the applicant attests that: a) the applicant is at least 21 years of age. b) consent is granted to representatives of the Alcoholic Beverage Control Department, Commission, State Bureau of Investigation (Bureau of Alcoholic Beverage Law Enforcement), and other law enforcement agencies to be admitted immediately and permitted without hindrance or delay to inspect the entire premises and all records of the permit holder. c) he/she has read and will abide by the provisions of Section 32A-6, Utah Code and all rules and directives of the Utah Department of Alcoholic Beverage Control; and understands that failure to adhere thereto shall constitute grounds for removal of said permit. d) the applicant does not and will not discriminate against persons on the basis of race, color, sex, religion, ancestry, or national origin. e) he/she has read and understands the statements made herein; that execution thereof is done voluntarily and by authorization of said organization, and that any false statement made on this application or any related document is a second degree felony. 6.05.08 American LegalNet, Inc. www.FormsWorkflow.com 15. The undersigned hereby makes application to the Utah Alcoholic Beverage Control Commission for a Special Use Permit (Public Service) and certifies that the information contained herein and attached hereto to be true and correct. Date: ___________________________ ________________________________ Applicant/owner of business STATE OF ________________________ COUNTY OF_______________________ Subscribed & sworn to before me this _______ day of ________________________________ Authorized signature ________________________________ Name/title ____________________, ________. _______________________________ Notary Public SEAL: 6.05.08 American LegalNet, Inc. www.FormsWorkflow.com UTAH DEPARTMENT OF ALCOHOLIC BEVERAGE CONTROL SPECIAL USE PERMIT (PUBLIC SERVICE) LOCAL CONSENT Date: _______________________________ Utah Department of Alcoholic Beverage Control Licensing & Compliance Section 1625 S 900 W PO Box 30408 Salt Lake City, Utah 84130-0408 _______________________________________________________, (City)(Town)(County) grants its consent to the issuance of a Public Service Special Use permit for__________________, a ________________________________ owned by ______________________________________, and located at____________________________________________________________________, pursuant to the provisions of Utah Code, 32A-6, for the purpose of purchase, storage, sale, consumption and/or other lawful use of alcoholic products as authorized by the Utah Department of Alcoholic Beverage Control. The applicant has met all ordinances relating to the issuance of the permit. Sincerely, ________________________________ Authorized Signature _______________________________ Name/Title 6.05.08 American LegalNet, Inc. www.FormsWorkflow.com UTAH DEPARTMENT OF ALCOHOLIC BEVERAGE CONTROL 1625 S 900 W • PO Box 30408 • Salt Lake City, UT 84130-0408 • Phone (801) 977-6800 • Fax (801) 977-6889 “PUBLIC SERVICE BOND” (SPECIAL USE) BOND # _______________________ KNOW ALL PERSONS BY THESE PRESENTS: That Principal, __________________________________________, a public service permittee, doing business as _____________________________________________________________, and Surety, _____________________________________, a corporation organized and existing under the laws of the state of ______________________ and authorized to do business in Utah, are held and bound unto the Utah Department of Alcoholic Beverage Control in the sum of $1,000, for which payment will be made, we hereby bind ourselves and our representatives, assigns, and successors firmly by these presents. Dated this _______ day of ___________________, _______. THE CONDITION OF THIS OBLIGATION IS SUCH THAT: WHEREAS, the above principal has made application to the Utah Alcoholic Beverage Control Commission for a public service permit pursuant to the provisions of 32A-6, Utah Code. NOW, THEREFORE, if said principal, its officers, agents and employees shall faithfully comply with the provisions of Title 32A, Utah Code, and the rules and directives of the Utah Alcoholic Beverage Control Commission and the Utah Department of Alcoholic Beverage Control, then this bond shall be void; but, if said principal, its officers, agents and employees fail to comply with the provisions of the laws, rules and directives or orders as the commission or department may issue, then this bond shall be in full force and effect and payable to the Utah Department of Alcoholic Beverage Control. This bond shall run for a continuing term effective ________________________ unless canceled by service of written notice upon the Utah Department of Alcoholic Beverage Control, which cancellation shall be effective 30 days after receipt of such notice; provided however, that no part of this bond shall be withdrawn or canceled while violations, legal actions or proceedings are pending against said permittee / principal. ___________________________________ Surety ___________________________________ Principal / Licensee ___________________________________ Attorney in fact ___________________________________ Authorized signature { Corporate Seal } 6.05.08 __________________________________ Name / Title American LegalNet, Inc. www.FormsWorkflow.com STATUTORY AFFIDAVIT FOR CORPORATE SURETY STATE OF: ____________________________ COUNTY OF: ____________________________ On the ________ day of _____________________, ______, personally appeared before me, ___________________________________, who, being by me duly sworn, did say that he / she is the attorney in fact of ____________________________________, Surety, and that said instrument was signed in behalf of said surety by authority, and acknowledged to me that he / she as such attorney in fact executed the same. ___________________________________ Notary Public Signature & Seal Note: Corporate surety's own affidavit also acceptable 6.05.08 American LegalNet, Inc. www.FormsWorkflow.com INFORMED CONSENT AND RELEASE OF LIABILITY PURPOSE: To determine, in accordance with Utah Code 32A-1-702 and 32A-1-703, if an applicant with the Department of Alcoholic Beverage Control has been: - convicted of a felony under federal or state law; convicted of a violation of a federal law, state law, or local ordinance concerning the sale, manufacture, distribution, warehousing, or transportation of an alcoholic beverage; convicted of a crime involving moral turpitude; convicted on two or more occasions within the previous five years, driving under the influence of alcohol, a drug, or the combined influence of alcohol and a drug. RELEASE I hereby authorize the Department of Alcoholic Beverage Control (DABC) to investigate my criminal history records to ascertain any and all information which may be pertinent to my qualifications as an applicant with the DABC. The release of any and all information is authorized whether it is of record or not, and I do hereby release all persons, firms, agencies, companies, groups or installations, whomsoever, from any damages of or resulting from, furnishing such information to the DABC. I further agree that a copy of this release will remain in my application file. ______________________________________________________________________ Name (please print; last, first, middle initial) _______________________________ Formerly used last names (please print) _________________________________ Applicant/ doing business as _______________________________ Signature _________________________________ Date 6.05.08 American LegalNet, Inc. www.FormsWorkflow.com (suggested attestation/stipulation letter to the DABC for a third-party national criminal background check) Date: ________________________ To whom it may concern: I, _____________________________, attest: 1. That I have submitted to the DABC the necessary fingerprint card(s) required for the application and consented to the fingerprint criminal background check(s) by the F.B.I. 2. That I am not aware of any criminal conviction that would disqualify me from applying for and holding a Utah Department of Alcoholic Beverage Control license or permit. I stipulate that if an F.B.I. report shows a criminal conviction that would disqualify me from holding the license, permit, or package agency, I shall immediately surrender the license, permit, or package agency to the department. I am enclosing a national criminal history background report from a third party background check reporting service. _____________________________________ Signature _____________________________________ Name/Title 6.05.08 American LegalNet, Inc. www.FormsWorkflow.com